Question

The nurse assesses the abdomen of a client with appendicitis. Which assessment finding(s) is the nurse likely to observe? (Select all that apply.)

Answer 1

Correct Answers:

Epigastric and periumbilical pain.
Pain typically localized to the right lower quadrant.

Rationale :

Epigastric and periumbilical pain

🟦 In early appendicitis, pain often begins as vague epigastric or periumbilical discomfort due to visceral nerve involvement.

🟦 This type of pain is typically dull and poorly localized because the visceral peritoneum is being stimulated.

🟦 As the inflammation progresses, the pain later localizes, but this initial periumbilical pain is a classic early feature.

🟦 Recognizing this pattern is important for early diagnosis before complications such as perforation occur.

🟦 Therefore, epigastric and periumbilical pain is a likely and expected assessment finding in a client with appendicitis.

Pain typically localized to the right lower quadrant

🟦 As appendicitis progresses, inflammation irritates the parietal peritoneum, causing pain to localize to the right lower quadrant (RLQ).

🟦 This is often described as sharp, localized pain at McBurney’s point in classic appendicitis.

🟦 Localized RLQ pain is a key clinical feature that strongly supports the diagnosis of acute appendicitis.

🟦 Rebound tenderness or guarding in the RLQ may also be present due to peritoneal irritation.

🟦 Thus, RLQ localized pain is a typical and expected finding in appendicitis and correctly selected.

A collection of fluid in the peritoneal cavity

🟦 A collection of fluid in the peritoneal cavity describes ascites, which is more commonly associated with conditions like liver cirrhosis, heart failure, or malignancy, not uncomplicated appendicitis.

🟦 While severe perforated appendicitis could eventually lead to peritonitis and fluid, this is a complication, not a typical initial finding.

🟦 Routine physical examination of a client with simple appendicitis would not usually reveal shifting dullness or fluid wave associated with ascites.

🟦 The primary expected findings are localized pain, tenderness, and possibly low-grade fever, not generalized fluid accumulation.

🟦 Therefore, this option does not describe a typical appendicitis finding and is incorrect.

A protrusion through the abdominal wall

🟦 A protrusion through the abdominal wall is characteristic of a hernia, not appendicitis.

🟦 Hernias involve protrusion of abdominal contents through a weakened area in the musculature and are typically visible or palpable.

🟦 Appendicitis is an inflammatory process of the vermiform appendix, which does not manifest as an external abdominal wall bulge.

🟦 The major concern in appendicitis is internal inflammation, possible perforation, and peritonitis, not physical protrusion.

🟦 Thus, this finding does not align with appendicitis and is an incorrect choice.

Cramping pain relieved by a bowel movement

🟦 Cramping abdominal pain relieved by a bowel movement is more consistent with irritable bowel syndrome (IBS) or functional bowel disorders.

🟦 In appendicitis, pain typically persists and progressively worsens rather than improving after defecation.

🟦 Appendicitis pain is usually constant and localized over time, especially in the RLQ, and not closely related to bowel movements.

🟦 Associating pain relief with bowel movement suggests colonic motility issues, not acute appendiceal inflammation.

🟦 Therefore, this symptom pattern is not typical for appendicitis and makes this option incorrect.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

These findings may be related to peripheral neuropathy.

Rationale :

🟩Peripheral neuropathy is a common complication of long-standing diabetes, especially in older adults.

🟩Loss of vibration sense and proprioception (position sense) in the feet is classic for sensory neuropathy.

🟩These changes increase risk for falls, foot injury, and ulcer formation, as the client may not detect trauma or abnormal pressure.

🟩The pattern of distal sensory loss, starting in the toes and feet, is characteristic of a “stocking” distribution neuropathy.

🟩Therefore, these neurological findings are highly consistent with diabetic peripheral neuropathy and should prompt further assessment and education.

These findings are consistent with infection of the great toe.

🟩An infection of the great toe (such as cellulitis or osteomyelitis) typically presents with redness, warmth, swelling, and pain, not loss of vibration and position sense.

🟩While infection risk is increased in clients with diabetes, the primary findings would be local inflammatory signs.

🟩Loss of sensation is more strongly associated with nerve damage, not acute infection.

🟩Sensory changes predispose the client to infection, but they do not represent infection itself.

🟩Therefore, interpreting these findings solely as infection is inaccurate and incomplete.

These findings are consistent with tumor in the cerebellum.

🟩A cerebellar tumor usually causes signs such as ataxia, intention tremor, dysmetria, or gait disturbance, rather than isolated distal sensory loss in the toes.

🟩Cerebellar lesions primarily affect coordination and balance, not peripheral vibration and position sense alone.

🟩The pattern here is distal, symmetric, and peripheral, which matches neuropathy more than central brain pathology.

🟩There is no mention of nystagmus, vertigo, or truncal ataxia, which would be expected in cerebellar involvement.

🟩Thus, attributing these findings to a cerebellar tumor is not clinically appropriate.

These are normal neurological findings related to aging.

🟩While mild sensory changes may occur with aging, complete or clear loss of vibration and proprioception in the toes and ankles is not considered normal.

🟩Dismissing such findings as age-related can lead to missed diagnosis of significant neuropathy.

🟩In an older adult with diabetes, such findings warrant careful assessment because they indicate nerve damage.

🟩Normal aging does not usually cause such localized, functionally significant deficits.

🟩Therefore, labeling these findings as normal is unsafe and incorrect.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

A client with a new onset of cold, pale foot and an absent pedal pulse.

Rationale :

⭐A cold, pale foot with an absent pedal pulse suggests acute arterial occlusion, which is an emergency.

⭐This presentation indicates severely impaired blood flow, placing the limb at risk for ischemia and tissue death.

⭐Acute arterial insufficiency is associated with the “6 Ps”: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

⭐Immediate assessment and provider notification are required to restore perfusion and prevent permanent damage or amputation.

⭐Therefore, this client is the highest priority and must be assessed first.

A client with a peripheral venous stasis ulcer that is draining serous fluid

⭐A venous stasis ulcer with serous drainage is typically a chronic condition and expected in chronic venous insufficiency.

⭐Although it requires ongoing wound care and monitoring, it usually does not represent an immediate limb-threatening emergency.

⭐There are no signs in the statement of acute infection, systemic symptoms, or sudden change.

⭐This client is important but can be safely assessed after the client with signs of acute arterial occlusion.

⭐Thus, this option does not represent the most urgent priority.

A client with peripheral arterial disease who reports leg pain after walking

⭐Leg pain after walking in a client with peripheral arterial disease describes intermittent claudication, a common and chronic manifestation.

⭐This symptom indicates reduced blood flow during exertion but typically resolves with rest.

⭐While it requires management, education, and risk factor control, it is not typically an emergent change.

⭐There are no signs here of sudden worsening, rest pain, or limb-threatening ischemia.

⭐Therefore, this client does not supersede the priority of a client with an acutely pulseless, cold extremity.

A client with chronic venous insufficiency who has bilateral ankle edema

⭐Bilateral ankle edema is a common and expected finding in chronic venous insufficiency.

⭐This condition reflects venous pooling and valve incompetence but is not typically immediately life- or limb-threatening.

⭐Although edema can cause discomfort and skin changes, it is generally a stable chronic issue.

⭐The nurse should still manage it with leg elevation, compression, and education, but it does not represent acute deterioration.

⭐Therefore, compared to sudden loss of pulse and pallor, this client is a lower priority.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Fanning out of all toes

Rationale :

🌙In an adult, fanning of the toes with dorsiflexion of the great toe is called a positive Babinski sign and is abnormal.

🌙A positive Babinski reflex in adults suggests upper motor neuron lesion involving the corticospinal tract.

🌙This finding can be associated with conditions such as stroke, spinal cord injury, multiple sclerosis, or brain lesion.

🌙It requires further neurological evaluation and timely reporting to the healthcare provider.

🌙Therefore, fanning out of all toes is a concerning abnormal plantar response in an adult client.

Plantar flexion of the toes

🌙Plantar flexion of the toes is the normal plantar reflex in adults.

🌙When the lateral sole of the foot is stroked, the expected response is downward flexion of the toes.

🌙This response indicates intact corticospinal tract function and normal neurological status.

🌙Because it is an expected finding, it should not cause concern for the nurse.

🌙Therefore, this option reflects a normal plantar reflex in an adult.

Inversion of the forefoot

🌙Some slight inversion or movement of the forefoot may occur during plantar stimulation and is generally not interpreted as Babinski.

🌙The key abnormal sign is dorsiflexion of the great toe with fanning, not minor inversion alone.

🌙Inversion without toe fanning is not a classic indicator of upper motor neuron lesion.

🌙This response is not typically considered a major abnormal plantar finding requiring urgent concern.

🌙Thus, this option is less concerning compared to a clear Babinski response.

Flexion of the forefoot

🌙Flexion of the forefoot can occur as part of a normal plantar flexion response in adults.

🌙The critical abnormal sign is extension and fanning of the toes, not flexion.

🌙Flexion suggests the reflex arc and corticospinal tract are functioning appropriately.

🌙In the absence of other abnormal signs, this finding would be considered within normal limits.

🌙Therefore, this option does not represent a concerning neurological abnormality.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

The client states that they have passed gas.

Rationale :

🔥 Passage of flatus (gas) is one of the most reliable indicators that bowel motility has returned after surgery.

🔥 It demonstrates that peristalsis is occurring, allowing gas to move through the intestines.

🔥 This finding is clinically more meaningful than hunger alone or bowel sound presence, which can be misleading.

🔥 Ensuring bowel function has returned helps prevent complications such as nausea, vomiting, or ileus when advancing diet.

🔥 Therefore, a client reporting they have passed gas is an appropriate indicator to consider diet advancement.

Abdominal distension and tympany with percussion is noted.

🔥 Abdominal distension and tympany suggest gas accumulation and possible ileus or obstruction, not normal motility.

🔥 Tympany on percussion indicates that air is trapped, often due to reduced or absent bowel movement.

🔥 This finding is concerning and would typically prompt further evaluation, not diet advancement.

🔥 Advancing diet in the presence of distension increases risk for worsening discomfort, vomiting, or aspiration.

🔥 Therefore, this option does not indicate safe return of bowel function.

There are absent bowel sounds in all quadrants.

🔥 Absent bowel sounds usually indicate hypoactive or absent peristalsis, especially in the immediate post-operative period.

🔥 Prolonged absence of bowel sounds raises concern for postoperative ileus or other complications.

🔥 Diet advancement requires evidence that the gut can move contents forward, not silence.

🔥 Giving food when bowel sounds are absent increases risk of nausea, vomiting, and intolerance to oral intake.

🔥 Thus, this finding is contraindicating diet progression, not supporting it.

The client requests breakfast because they are hungry.

🔥 A sensation of hunger may occur before full bowel motility has returned and is not a reliable clinical indicator.

🔥 Appetite can be influenced by hydration status, medications, or habit, independent of gut function.

🔥 Without objective signs of bowel activity, using hunger alone to advance diet is unsafe.

🔥 The nurse should prioritize physical evidence of peristalsis, such as flatus or stool passage, over subjective hunger.

🔥 Therefore, this option does not adequately confirm return of bowel motility.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Check peripheral pulses.

Rationale :

🔷 Bilateral lower extremity hair loss and prolonged capillary refill (5 seconds) suggest possible peripheral arterial disease (PAD).

🔷 The next appropriate step following the nursing process is further assessment, specifically checking peripheral pulses to evaluate perfusion.

🔷 Assessing dorsalis pedis and posterior tibial pulses helps determine the severity of arterial compromise.

🔷 This information will guide whether the findings require urgent provider notification or routine follow-up.

🔷 Therefore, checking peripheral pulses is the most appropriate immediate nursing action.

Monitor the blood pressure.

🔷 Although blood pressure is important in vascular disease, it does not directly assess local limb perfusion like pulse palpation does.

🔷 A normal systemic blood pressure does not rule out localized arterial obstruction in the lower extremities.

🔷 The priority based on the specific findings (hair loss and delayed cap refill) is to evaluate distal circulation.

🔷 Blood pressure monitoring is helpful but is not the most immediate, targeted assessment in this situation.

🔷 Thus, this option is less appropriate than directly checking peripheral pulses.

Document the finding.

🔷 Simply documenting the findings without further assessment does not meet the standard of comprehensive nursing care.

🔷 Delayed capillary refill and hair loss may indicate chronic arterial insufficiency, which requires more detailed evaluation.

🔷 The nurse must first gather additional objective data, such as pulse quality, before final documentation and reporting.

🔷 Documentation is important but should follow appropriate assessment, not replace it.

🔷 Therefore, this response alone is insufficient as the next action.

Notify the healthcare provider.

🔷 While these findings may eventually need to be reported, the nurse should first perform a more complete vascular assessment.

🔷 Notifying the provider without checking peripheral pulses, temperature, and color leaves the clinical picture incomplete.

🔷 The nursing process requires thorough assessment before notification, unless there is an obvious emergency.

🔷 Additional data will help the provider make informed decisions about diagnostic tests or interventions.

🔷 Thus, immediate notification before further assessment is premature and not the best next step.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Assess for the pulse with a Doppler.

Rationale :

💎 The client had a previously palpable dorsalis pedis pulse (2+ and regular), and now it is non-palpable, which is a significant change in vascular status.

💎 The immediate priority is to confirm whether the pulse is truly absent by using a Doppler device, a more sensitive method of pulse assessment.

💎 Using a Doppler helps determine whether the issue is poor perfusion versus difficulty palpating due to edema, dressing, or technique.

💎 This action is consistent with the assessment phase of the nursing process before notifying the provider of an emergent vascular compromise.

💎 If the pulse is still absent by Doppler, this would suggest acute arterial occlusion and requires urgent provider notification.

Document the absent pedal pulse

💎 Simply documenting the absent pedal pulse without further assessment fails to respond to a potentially limb-threatening change.

💎 The nurse must first verify the finding using a Doppler to ensure the change is accurate and not due to assessment error.

💎 Immediate documentation alone delays critical intervention for possible acute ischemia.

💎 A previously present pulse becoming non-palpable after femoral vascular surgery can indicate post-op complication such as thrombosis.

💎 Therefore, this option is incomplete and unsafe as the next action.

Auscultate the client's heart and lungs

💎 Auscultating heart and lungs is important in general assessment, but it does not address the specific acute change in peripheral circulation.

💎 The most pressing issue is possible loss of blood flow distal to the surgical site, not central cardiopulmonary function at this moment.

💎 Focusing on heart and lung sounds would delay targeted vascular assessment needed for this extremity change.

💎 A missing distal pulse in a limb post-vascular surgery is a priority localized problem requiring direct vascular assessment.

💎 Thus, this is not the most appropriate immediate next step.

Take the client's blood pressure

💎 Measuring blood pressure may provide information about systemic circulation, but it does not directly evaluate local arterial perfusion in the affected limb.

💎 A client can have a normal blood pressure while still experiencing acute arterial occlusion in one extremity.

💎 The specific concern is the loss of distal pulse in the operative leg, which requires focused vascular assessment.

💎 Blood pressure can be assessed later but is not the priority intervention in response to a suddenly absent pedal pulse.

💎 Therefore, this response is less appropriate than using a Doppler to reassess the foot pulse.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Monitor for skin changes daily.

Rationale :

🟢 Clients with advanced venous disease are at high risk for skin breakdown, venous stasis ulcers, and dermatitis.

🟢 Teaching them to monitor for skin changes daily helps with early detection of redness, discoloration, cracks, or open areas.

🟢 Early recognition of changes allows for prompt treatment, reducing the risk of infection and chronic nonhealing ulcers.

🟢 This intervention supports self-management and prevention, which are key in chronic venous insufficiency care.

🟢 Therefore, including daily skin inspection in the teaching plan is appropriate and evidence-based for venous disease.

Limit use of compression stockings

🟢 Clients with chronic venous insufficiency often benefit from regular use of compression stockings to improve venous return.

🟢 Compression helps reduce edema, venous pooling, and discomfort in the lower extremities.

🟢 Limiting their use would be counterproductive and may worsen swelling and skin changes.

🟢 Teaching should emphasize proper fit, correct application, and consistent use, not restriction.

🟢 Therefore, advising to limit compression stockings is incorrect for venous disease management.

Use heating pads on the legs

🟢 Applying heating pads to legs with venous disease is risky because clients may have decreased sensation and are prone to burns.

🟢 Heat also causes vasodilation, which can worsen venous congestion and edema.

🟢 Evidence-based teaching recommends avoiding direct heat on compromised extremities, especially in vascular disease.

🟢 Safer strategies include elevation and compression, rather than external heating devices.

🟢 Thus, encouraging heating pad use on the legs is inappropriate and unsafe.

Do not elevate the legs regularly

🟢 Elevating the legs is a cornerstone intervention to promote venous return and reduce venous pressure and edema.

🟢 Telling clients not to elevate their legs contradicts standard care for venous insufficiency, where elevation helps relieve symptoms.

🟢 Regular leg elevation above the level of the heart helps reduce swelling and discomfort.

🟢 Failing to elevate the legs can lead to persistent edema and deterioration of skin integrity.

🟢 Therefore, this teaching is incorrect and should never be recommended for venous disease.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Possible bowel obstruction

Rationale :

✨ A scaphoid abdomen (sunken appearance) with visible slow peristaltic waves suggests that the intestines are working hard against a mechanical blockage.

✨ These subtle, slow ripples moving across the abdomen are classic signs of enhanced visible peristalsis, often seen proximal to an obstruction.

✨ In bowel obstruction, the bowel attempts to push contents forward, resulting in exaggerated peristaltic activity that may be seen on inspection.

✨ This finding should prompt further assessment for other signs such as pain, distension, vomiting, and altered bowel sounds.

✨ Therefore, documenting the finding as possible bowel obstruction is accurate and clinically appropriate.

Normal peristalsis

✨ While some peristaltic movement can rarely be seen in very thin individuals, more notable visible waves are generally not considered normal.

✨ The description of subtle, slow ripples across the abdomen suggests exaggerated peristalsis, not normal quiet intestinal activity.

✨ Normal peristalsis is usually auscultated as bowel sounds, not prominently seen as rippling.

✨ Labeling this as normal could delay recognition of significant pathology such as obstruction.

✨ Therefore, documenting this as normal peristalsis is inaccurate.

Possible abdominal aortic aneurysm

✨ An abdominal aortic aneurysm (AAA) classically presents as a pulsatile mass, often in the mid-abdomen, with a prominent pulsation, not slow peristaltic ripples.

✨ The movement from an aneurysm is synchronous with the heartbeat, rather than slow waves moving across the abdomen.

✨ There is no mention of a central pulsatile mass, which would raise suspicion for AAA.

✨ The described movement aligns better with bowel activity, not arterial pulsation.

✨ Therefore, interpreting this as possible AAA does not fit the described assessment findings.

Abdominal fluid waves

✨ Fluid waves are associated with ascites, which is the accumulation of fluid in the peritoneal cavity.

✨ Fluid wave assessment involves percussing one side of the abdomen and feeling for a transmitted wave on the opposite side, not visually observing ripples.

✨ Ascites typically results in a distended, protuberant abdomen, not a scaphoid (sunken) abdomen.

✨ The observed slow ripples are much more consistent with visible peristalsis than with free fluid movement.

✨ Thus, this option does not match the findings of a scaphoid abdomen with visible slow waves.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Sharp, stabbing pain as pressure is released from the abdomen

Rationale :

🟡Blumberg’s sign describes rebound tenderness: pain occurring when pressure is suddenly released from the abdomen.

🟡This is a classic sign of peritoneal irritation, often seen in conditions such as peritonitis or appendicitis.

🟡The key feature is that the pain is worse upon release rather than during application of steady pressure.

🟡This indicates inflammation of the parietal peritoneum, which reacts sharply when it is suddenly stretched back.

🟡Therefore, sharp, stabbing pain upon release of pressure correctly describes a positive Blumberg’s sign.

A collection of fluid in the peritoneal cavity that is felt against the fingertips

🟡A collection of fluid in the peritoneal cavity is more consistent with ascites, not Blumberg’s sign.

🟡The technique to detect fluid involves assessing for a fluid wave or shifting dullness, not rebound tenderness.

🟡Feeling fluid movement against the fingertips is related to fluid wave test, not peritoneal irritation.

🟡Blumberg’s sign specifically evaluates pain on release of pressure, not presence of free fluid.

🟡Thus, this description is incorrect for Blumberg’s sign.

Periumbilical pain, typically localized to the right lower quadrant (RLQ)

🟡This description matches the typical pain progression in appendicitis, starting with periumbilical pain that later localizes to the RLQ.

🟡While appendicitis may also show positive Blumberg’s sign, this option does not specifically define rebound tenderness.

🟡It focuses on location and progression of pain, not pain elicited by release of abdominal pressure.

🟡Blumberg’s sign is a physical exam maneuver, not a description of the general pain pattern.

🟡Therefore, this answer does not accurately define a positive Blumberg’s sign.

Knife-like pain in the upper right quadrant of the abdomen during percussion

🟡Knife-like RUQ pain during percussion is more suggestive of liver or gallbladder pathology, such as cholecystitis.

🟡Blumberg’s sign does not focus on percussion but on palpation and release of pressure.

🟡Pain during percussion relates more to organ tenderness or inflammation, not rebound tenderness.

🟡The key diagnostic feature of Blumberg’s sign is pain upon release, not during the percussive strike.

🟡Hence, this description does not correspond to a positive Blumberg’s sign.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Examplify W4 NR304 Exam 1

No.

1 :
The nurse assesses the abdomen of a client with appendicitis. Which assessment finding(s) is the nurse likely to observe? (Select all that apply.)

2 :
During the neurological assessment of an older adult who has diabetes, the nurse notes the client is unable to feel vibrations from a tuning fork on the great toe and ankle and is unable to sense the position of the great toe. How should the nurse interpret these findings?

3 :
A nurse cares for a group of clients with peripheral vascular disease. Which client should the nurse assess first?

4 :
The nurse is performing a plantar reflex assessment on an adult client. Which finding should concern the nurse?

5 :
The nurse is caring for a client post-operatively. Before advancing the client's diet, which finding should the nurse identify to ensure the client regained bowel motility?

6 :
A nurse assesses that a client has bilateral lower extremity hair loss and a capillary refill of 5 seconds for both feet. What should the nurse do next?

7 :
During the initial assessment of a client who is 30 minutes post-operative following femoral vascular surgery, the nurse palpates the dorsalis pedis pulse as 2+ and regular. Two hours later, the pulse is no longer palpable. What action should the nurse take next?

8 :
The nurse plans teaching for a client with advanced venous disease. What should the nurse include in the teaching?

9 :
A nurse is assessing a client who has a scaphoid abdomen. During the assessment, the nurse notes subtle, slow ripples moving slowly across the abdomen. How should the nurse document these findings?

10 :
Which of the following symptoms describes a positive Blumberg's sign?

Connect With Us

Examplify W4 NR304 Exam 1

No.

1 : The nurse assesses the abdomen of a client with appendicitis. Which assessment finding(s) is the nurse likely to observe? (Select all that apply.)

2 : During the neurological assessment of an older adult who has diabetes, the nurse notes the client is unable to feel vibrations from a tuning fork on the great toe and ankle and is unable to sense the position of the great toe. How should the nurse interpret these findings?

3 : A nurse cares for a group of clients with peripheral vascular disease. Which client should the nurse assess first?

4 : The nurse is performing a plantar reflex assessment on an adult client. Which finding should concern the nurse?

5 : The nurse is caring for a client post-operatively. Before advancing the client's diet, which finding should the nurse identify to ensure the client regained bowel motility?

6 : A nurse assesses that a client has bilateral lower extremity hair loss and a capillary refill of 5 seconds for both feet. What should the nurse do next?

7 : During the initial assessment of a client who is 30 minutes post-operative following femoral vascular surgery, the nurse palpates the dorsalis pedis pulse as 2+ and regular. Two hours later, the pulse is no longer palpable. What action should the nurse take next?

8 : The nurse plans teaching for a client with advanced venous disease. What should the nurse include in the teaching?

9 : A nurse is assessing a client who has a scaphoid abdomen. During the assessment, the nurse notes subtle, slow ripples moving slowly across the abdomen. How should the nurse document these findings?

10 : Which of the following symptoms describes a positive Blumberg's sign?

1 :
The nurse assesses the abdomen of a client with appendicitis. Which assessment finding(s) is the nurse likely to observe? (Select all that apply.)

2 :
During the neurological assessment of an older adult who has diabetes, the nurse notes the client is unable to feel vibrations from a tuning fork on the great toe and ankle and is unable to sense the position of the great toe. How should the nurse interpret these findings?

3 :
A nurse cares for a group of clients with peripheral vascular disease. Which client should the nurse assess first?

4 :
The nurse is performing a plantar reflex assessment on an adult client. Which finding should concern the nurse?

5 :
The nurse is caring for a client post-operatively. Before advancing the client's diet, which finding should the nurse identify to ensure the client regained bowel motility?

6 :
A nurse assesses that a client has bilateral lower extremity hair loss and a capillary refill of 5 seconds for both feet. What should the nurse do next?

7 :
During the initial assessment of a client who is 30 minutes post-operative following femoral vascular surgery, the nurse palpates the dorsalis pedis pulse as 2+ and regular. Two hours later, the pulse is no longer palpable. What action should the nurse take next?

8 :
The nurse plans teaching for a client with advanced venous disease. What should the nurse include in the teaching?

9 :
A nurse is assessing a client who has a scaphoid abdomen. During the assessment, the nurse notes subtle, slow ripples moving slowly across the abdomen. How should the nurse document these findings?

10 :
Which of the following symptoms describes a positive Blumberg's sign?